Conservative management
Cleft type: 1
Advantages:
Noninvasive
May allow aspiration to resolve on its own
No hospitalization needed
Relatively minimal costs
Disadvantages:
May not result in improvement
May prolong an eventual endoscopic intervention
Thickening agents may aggravate constipation and dehydration
Requires caregiver support.
Other complications and risks exist
Conservative medical management is commonly recommended as a first-line treatment for type 1 clefts in children with normal growth and no respiratory compromise (IPOG, 2017). These strategies may also help optimize the swallow of children with more severe clefts who will ultimately have a surgical repair. Generally, studies show about 50 percent of children with a type 1 cleft will benefit to some degree from conservative management.
If the child has any other medical issues, especially airway abnormalities, they are less likely to benefit from conservative management. If the child has any other midline anomalies, they should be promptly evaluated for an associated genetic syndrome. In high risk cases (prematurity, neuromuscular disorder, genetic syndrome, etc.), some ENTs trial conservative management, while others recommend immediate endoscopic intervention.
It is important to note that a mild cleft may not be the primary or only cause of a child’s aspiration and swallowing difficulties. Dysphagia is a complex condition with many contributing drivers. This makes it difficult to know whether conservative management or endoscopic intervention will be most helpful to the child. Since aspiration may resolve over time and surgery may not correct aspiration, a period of conservative management is often recommended for type 1 clefts.
However, immediate endoscopic intervention may be needed if the child has:
compromised respiratory function
slow growth/failure to thrive
other medical conditions
Conservative management strategies include:
Feeding therapy:
The length of therapy varies, but usually lasts for three to 12 months. Feeding therapy is conducted by an SLP or OT who is skilled in pediatric dysphagia and involves strategies such as:
positioning
thickening
maneuvers/exercises (only with an expert)
managing the environment (feeding routines, responsive feeding, regulating sensory needs)
Reflux control:
Most doctors prescribe medication if reflux symptoms are present, while a minority of doctors prescribe medications to all children with a cleft. In severe cases, reflux surgery may be advised. Some children have allergies or intolerances that worsen reflux symptoms, so dietary changes may be recommended.
Feeding tube:
Some children may benefit from receiving food and water through a feeding tube. Doctors may recommend using a feeding tube, such as a temporary NG tube or a longer-term G-tube, J-tube, or G/J-tube.
Breathing support:
Some children with breathing difficulties may benefit from various medications, such as steroids, albuterol, or racemic epinephrine in emergencies. In more severe cases, a tracheostomy may be needed.